A scathing report looking into care delay problems at the Phoenix Veterans Affairs Health system recommends an overhaul in scheduling practices, better training and oversight for all employees, and possible firing of numerous system leaders as starting points for fixing cultural problems there.
The 143-page report by the VA inspector general was released as President Obama and VA Secretary Bob McDonald spoke at the American Legion's annual convention about ways to both repair the department's battered image after months of scandal and regain the trust of veterans.
"VA will get through its present difficulties, and be stronger for it," McDonald promised the convention attendees.
Allegations of monthslong delays for medical appointments in Phoenix and secret waiting lists to conceal institutional problems led to nationwide scrutiny of VA problems and the May resignation of former VA Secretary Eric Shinseki.
The four-month-long Phoenix investigation uncovered dozens of incidents of delayed care for seriously ill patients, including a retiree who waited nine weeks after a lung cancer diagnosis for follow-up care and a 60-year-old veteran who received a follow-up care appointment three months after his death.
"We identified multiple types of scheduling practices in use that did not comply with [Veterans Health Administration] policy," the report states. "These practices became systemic because VHA did not hold senior headquarters and facility leadership responsible and accountable."
But the report deflects the most damaging accusation leveled against regional and national VA leadership: that incompetence and mismanagement may have led to the deaths of veterans.
Whistleblowers and lawmakers critical of the department have claimed that care delays in the Phoenix system led directly to the deaths of at least 40 veterans. Investigations said they found "troubling lapses in follow-up, coordination, quality, and continuity of care" but no direct link to patient deaths.
VA Deputy Secretary Sloan Gibson called that finding reassuring but little comfort given the failings detailed.
"Veterans were waiting too long for care," he said. "I am relieved that there weren't findings that veterans died as a consequence of those delays, but that doesn't excuse the delays. That was unacceptable. It doesn't meet our standard of care, it doesn't meet what we promised to deliver."
Obama on Tuesday told Legion members he is committed to fixing the VA.
"Despite all the good work that the VA does every day, despite all the progress that we've made over the last several years, we are very clear-eyed about the problems that are still there," he said. "Those problems require us to regain the trust of our veterans, and live up to our vision of a VA that is more effective and more efficient and that truly puts veterans first."
The president also announced a host of new executive actions aimed at expanding suicide prevention programs, recruiting thousands of medical professionals into VA hospitals,and creating better medical transitions from military health care to VA programs.
The inspector general report outlines 24 recommendations to improve operations at Phoenix, all of which VA officials agreed to and several of which department leaders insist are already underway. McDonald has ordered an outside review of all medical appointment scheduling practices and ordered new training throughout the department.
Both McDonald and Gibson also promised accountability for past mismanagement, although neither has provided a time line for when individuals will be fired in Phoenix.
The director of the Phoenix system and two other top leaders were placed on administrative leave in May, but have continued to collect their salaries while administrative actions proceed.
The inspector general report also calls for personnel actions against individuals responsible for "possible patient injury and allegations of poor quality of care," but offers no timeline for that response.
The inspector general's office said staff members are working with FBI and Justice Department officials on nearly 100 cases involving possible fraud and obstruction charges related to problems at VA facilities nationwide. The Office of Special Counsel has also opened several dozen investigations into reports of whistleblower retaliation.
Leo covers Congress, Veterans Affairs and the White House for Military Times. He has covered Washington, D.C. since 2004, focusing on military personnel and veterans policies. His work has earned numerous honors, including a 2009 Polk award, a 2010 National Headliner Award, the IAVA Leadership in Journalism award and the VFW News Media award.
